- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $1,448.30
| Facility | | $1,448.30 | $1,448.30 | $1,448.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $1,530.55
| Professional | | $1,448.30 | $1,448.30 | $1,530.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,026.47 / $7,026.47 / $7,026.47
| Facility | | $7,026.47 | $7,026.47 | $7,026.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $702.00 / $891.54
| Professional | | $198.37 | $702.00 | $891.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,896.60
| Facility | | $1,448.30 | $1,448.30 | $2,896.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,204.94 / $3,204.94 / $3,204.94
| Professional | | $3,204.94 | $3,204.94 | $3,204.94 |